01/31/18

With the End in Mind & Letting Go review: Ways to have a good death

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By Gail Bell

In my early years in hospital pharmacy we made Brompton’s Cocktail in accordance with prevailing clinical guidelines, that is, “to order, for terminal patients”. The cocktail consisted of morphine crystals, cocaine powder, alcohol, syrup and chloroform water and it was given sparingly, on the fourth hour, to a patient in extremis.

In her welcome, engaging book, With the End in Mind, Dr Kathryn Mannix, revisits this practice, using it to highlight the days when medical morphine was spooned out cautiously, often in doses too feeble or too potent for the individual, the days, she writes “before we had worked out how to titrate painkillers”.

Informed by her staff that a new hospice admission was refusing morphine on the basis of bad memories of Brompton’s Cocktail, she visited the dissenter personally and discovered a retired psychiatrist who had once tutored her at medical school. In his experience, patients were rendered semi-conscious by the “industrial strength drug mixture”, unable to speak coherently or with dignity, attributes he could not accept for himself or put his family through. Mannix conquered the role reversal implications of ministering to her one-time mentor and employed her softly, softly conversational approach to bring him to a position where “he might allow that medicine had progressed” since the 1980s.

Mannix is a British palliative-care specialist who, in her own words has spent “half a lifetime … keeping company with the dying”. Her book is part memoir, part witnessing and a good part wise counsel in best practice for the dying. Her strong suit is conquering the moment with a quiet conversation, often begun in an atmosphere of heightened emotions, fixed beliefs and the competing interests of family gathered at the deathbed.

She is a natural storyteller with an eye for detail, dialogue and the telling moment. “I am offering the reader my eyes and ears, my seat at the table, my place in the conversations, and my perspective on events.”

As recently as 2016, Australian author, the late Cory Taylor, wrote in Dying: A Memoir: “For so many of us, death has become the unmentionable thing, a monstrous silence. But this is no help to the dying, who are probably lonelier now than they’ve ever been.”

Mannix wants the lost vocabulary as well as the etiquettes of dying brought back to the death bed. She teaches families what to expect, to give each phase of the body’s shutting down a name. She begins with “the gradual increase in daytime sleeping, the gradual reduction in time spent awake” and ends at Cheyne-Stokes pattern breathing, cycles of fast-to-slow breaths, often with long gaps between, until the “gentle ending of the cycle”. The approach of death, she hopes, will one day be conceived more generally as a process, like birthing, moving stage by stage to an outcome.

The other string to Mannix’s bow is her qualification as a Cognitive Behaviour Therapist, a discipline she used to develop coping strategies for people facing impending death (she wrote Britain’s innovative CBT First Aid Plan for palliative care).

This psychological intervention is reported to dramatic effect in the case study of 22-year-old Mark, who was in the end stage of cystic fibrosis with no transplant available. He was incapacitated by panic attacks, gripped by fear and very angry. Mannix took his fear, put it on paper in a diagram and allowed him to discover how adrenaline was driving the circuit, creating a self-defeating increase in his panic.

The liberating effect of studying the pattern allowed Mark a few months of relative freedom from fear (including a pub outing with mates) before he developed a fatal chest infection. Mannix was called to see him and was greeted by Mark at his most triumphant: “You should be f—ing proud of me … I’m f—ing dying and I’m not f—ing panicking!”

Dr Charlie Corke is an Australian intensive-care specialist and a strong proponent of timely advanced-care planning. His book, Letting Go, walks the same terrain as Mannix but his map is the ICU of a busy hospital where decisions are made on the run, as it were, not in the relative quiet of a hospice setting. His patients arrive in ambulances, desperately ill, close to death, often unable to communicate their wishes, and reliant on a frantic relative’s instructions.

“Doctors and families feel a tremendous responsibility to do something to save (or extend) life,” he writes. “This happens however unpleasant the medical journey is likely to be — and however poor the outcome.”

In crisp, clear prose Corke confronts the reader with the scenario most of us in Western society are likely to face after a period of declining health and function: ambulance, hospital, unconsciousness, no plan in place, family disagreements about treatment, escalation of medical intervention, and finally, our last days spent “connected to machines, cared for by strangers, and separated from family”.

“Medical terminology will dominate our last days and weeks,” he writes.

While not denigrating his own profession, he takes a humanistic approach to its limits. The reader learns of the “covenantal ethic” whereby a surgeon promises to use his or her skills “to battle death on behalf of the patient. In return, the patient puts their trust in the surgeon and accepts whatever is required”. The covenant can have unwanted outcomes, notably when a surgeon has not been given prior permission “to stop if things [go] badly”.

Keeping in mind that “saving is what doctors do”, Corke advocates forward planning well in advance of old age and infirmity, in writing, with the added backup of an appointed decision maker.

He presents brief case histories to show how things can go wrong. Rosalie’s story, for instance, gives pause for thought when appointing a decision maker. She chose May, her only daughter, as her agent. May gave up her job to care for her mother and swore to sensitively respect her mother’s wishes. When Rosalie was taken to hospital after developing a severe infection, May acted upon her mother’s stated wishes: comfort care with no burdensome attempts at cure.

However, May’s five brothers arrived at the hospital and exerted pressure on May to instruct the doctors to do everything possible to “save Mum”. Rosalie was put on life support, had six operations, developed multiple organ failure and finally died. May, writes, Corke, “seemed crushed and guilty”. The message is clear, he summarises, inform everyone concerned beforehand and obtain reassurance that all will respect the bargain.

Making choices is hard. Corke suggests that “prior (well-considered) wishes should carry more weight than a later decision made in a crisis”. And he covers all the bases, from religious to legal ramifications, to distorted portrayals of the success rates of CPR in TV and film, and emotive journalism around withdrawing life support.

The book ends with practical tips and accompanying case histories, tying up Corke’s thesis with the kind of wise, informed advice we crave in the era of Dr Google, advice that may be more useful than we think in light of the recent Productivity Commission Report into palliative care in Australia. Seventy per cent of Australians wish to die at home, without pain and surrounded by family. The “without pain” part is the work of the severely underfunded palliative care sector. Fourteen per cent achieve that goal.

As a manual for how to avoid ending up in ICU, in what one of Corke’s patients called “the bad bit at the end”, Letting Go is a guide book for our age.

Complete Article HERE!

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01/23/18

With the End in Mind and From Here to Eternity review – how to banish fear and shame around dying

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Two very different books about death, by Kathryn Mannix and Caitlin Doughty, look at how we can face our final days with practicality, adventure and joy

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When John Keats was dying of TB in Rome, just 25 and far from family and home, he wrote a series of beautifully judged, empathetic letters of farewell that deal lightly (yet never falsely) with his physical suffering and his emotional anguish. From the shrinking circle of his life, from his frail body drowning in itself, he reached outwards towards the friends he was leaving. In his final letter, he wrote of living a “posthumous existence”; his last phrase becomes his eloquent, courteous and self-effacing goodbye before he exits the stage on which he has had such a small parcel of time: “I always made an awkward bow.” Dying as a performance, dying as an art and a practice, dying as something solemnly profound and sorrowful and at the same time as normal, natural; dying as physical and as spiritual; dying as the end of a whole world because, as Oliver Sacks wrote, when dying himself: “There is no one like anyone else, ever.”

We live in our bodies and die in our bodies. In previous centuries, death was familiar and not hidden behind institutional walls: before the 20th century, there would have been scarcely an adult who had not seen their parents, some of their children, and their friends die. Moreover, there was faith that it was not the end. People witnessed death, dealt with it, prepared for it, even embraced it (John Donne used to sleep in his own coffin; Jeremy Taylor wrote his 17th-century manuals for the soul, Holy Living and Holy Dying, which became the preeminent works of the ars moriendi tradition; in The Tempest, Prospero consigns himself to an old age in which every third thought will be of death). Now, although we live with the sense of our own ending, we don’t really. We know we’re going to die, but we don’t know. Our body doesn’t know, except in dizzying moments of terror, until the sentence has been uttered and the gallows are being built under the window. Even then, death is often held at bay and life prolonged at all costs: the fragile and disintegrating body is plugged into machines, pumped full of oxygen and blood and drugs, its gallant heart restarted and kept going, no matter the pain, no matter the hopelessness of the endeavour, no matter that at a certain point this isn’t living, just a slowed-down, drawn-out, painful and undignified dying.

It has become easier to live longer, but harder to die well. Most people want to die at home; most die in hospital. Most want to be with family; often they are alone or with strangers. “Their death has been stolen from them,” writes Seamus O’Mahony in his bracing and unsentimental account of dying, The Way We Die Now, which charts how something that used to be public and acknowledged, with a common script, has become an aggressively medicalised and bureaucratic process placed in the hands of experts; sometimes banal, sometimes farcical, sometimes painful or undignified. Modern, sanitised death becomes a dirty little secret, almost embarrassing: our language circles round it, we don’t like to name it, cross the road to avoid those recently touched by it, and shy away from the physical, squeamish fact of it, so that the dead body is whisked away, frequently embalmed (for fear of its smell), cremated in “facilities” that are often in industrial zones.

Lady with the Lamp: Florence Nightingale tending the sick and dying.

Have we lost our way with dying and with death? In the last few years, there has been a crowd of books by doctors, scientists, writers and people who are scrutinising their own departure that have sought to show us different, kinder ways of ending: Atul Gawande, Oliver Sacks, Henry Marsh, Jenny Diski, Tom Lubbock, Marion Coutts, Paul Kalanithi, the luminous final poems of Helen Dunmore… the list is long. Behind them all stands the austere, magisterial work by Sherwin Nuland written in 1993, How We Die. Now Kathryn Mannix joins this distinguished group and her voice, though quiet and calm, is distinctive. A palliative doctor (or “deathwife”), she spends her days with the terminally ill and their families, witnessing and supporting them at times of intense suffering, terror and loss. About a quarter of deaths are sudden and unexpected, but she usually sees the ones that come slowly, over months or years, and while much of her work is diagnostic and medical, one of her crucial tasks is to help those who are dying and their families find ways of dealing with life’s final, great event.

With the End in Mind: Dying, Death and Wisdom in an Age of Denial is Mannix’s account of ways of dying, through a series of vivid stories, most of which disguise the protagonist, some of which are composite tales stitched together from several cases, and all of which are heart-wrenching testimonies to human courage and love. Her purpose is to describe many forms of death – the young man with testicular cancer treated in the room dubbed “the Lonely Ballroom”, the dying mother in the hospice who manages to walk her daughter up the aisle, the 22-year-old with cystic fibrosis, the teenager with leukaemia – and to show how in each case, while a death may be emotionally harrowing, it need not be intolerably painful; while it may be tragic, it need not be ghastly or full of the chaos that accompanies too many ends.

Like those romantic portraits of Florence Nightingale holding her lamp aloft as she walked between beds of maimed and dying soldiers, Mannix’s aim is to shed a soft, clear light on a subject she feels is too often avoided. She wants us to think about what dying and death mean for others and for ourselves and take the fear and recoil out of the subject. Mild, tender and conciliatory, she is punctiliously even-handed. If one story shows how denial is toxic and the truth needs to be gradually and gently revealed, in another she demonstrates the usefulness of denial; if one describes how precious time can be won for a patient, another is an example of how prolonging life can be cruel and death a necessary kindness. One person’s good death is not another’s – we all need to find our own way to take our bow and leave the stage.

I agree with almost everything Mannix says; I would like her, or someone like her, to be my compassionate, wise doctor when I lie dying, easing me out when my time has come. Yet in her desire to show that death can be well managed, she leaves out the mess, fear, pain and unpredictability of so much dying – its scandal, its wildness and its impossibility. Not all passing can be gentle and not everyone can be brought to acceptance in the face of their own obliteration. However we dress it up and think about it, death remains blankly ungraspable and stark.

Enter Caitlin Doughty, American mortician, joyful member of the death-positive movement, who describes what happens to our mortal remains with boisterous relish – “ya tell it like it is”, she wrote in her first book, Smoke Gets in Your Eyes. Skin slip is skin slip; putrefaction stinks. The body fails and the body rots and death is a tragedy and a farce. Jaunty, boisterous and unsentimental, Doughty believes that we in the west have made death and its aftermath into a corporate, perfunctory affair, in which the meaning of an ending is denied. Her mission is to “reclaim public understanding of dying” and to bring individuality and joy back into our dealings with the dead – and so, in From Here to Eternity, she embarks on a journey of discovery: to the only open pyre in America; to a sky burial in Tibet, where the body breaker slices the corpse into parts, pounds the flesh with a mallet, mixes it with barley flour and yak butter or milk, and leaves it to the shrieking vultures to consume; to burial towers in India; to the people of Tana Toraja in Indonesia, where mummified bodies are cared for in their home (offered food, dressed, even given a bed with the living) over months or years until the family can sacrifice an animal and put the dead to their final rest; to Barcelona’s mass bone pits; Mexico’s Day of the Dead. Skulls used as flowerpots, bodies made into compost on a body farm, corpses covered with rose petals, funerals conducted by men with dreadlocks and purple frock coats – what Doughty relishes are those rituals that acknowledge death, its bodily fact and its emotional enormity.

And although the book is in love with extremes, it actually shares Mannix’s desire to be balanced: one culture’s practice is another culture’s taboo. We might not like the thought of ripping the rotting flesh from our loved one’s bones, but for some, burning a body is equally repugnant. What is important is “to hold the space” – to banish our fear and shame, and create a ring of safety around the grieving family and friends where they can mourn, each in their own way.

Animals perish; only humans die – because we are creatures who are aware of our own mortality. This awareness, which can feel vertiginous, unendurable, is also what gives us selfhood, and life shape and meaning. “Death destroys a man; the idea of death saves him,” wrote EM Forster. It is Henry James’s “distinguished thing”, Martin Amis’s backing to the mirror, Rochefoucauld’s sun that we must not stare at too long lest we go blind with seeing. It’s the great nothing; the everything, which makes us and unmakes us, and to which we all come in the end. Nothing is more certain; nothing more bewildering, strange, scandalous, downright impossible, forever true.

Complete Article HERE!

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01/19/18

‘The Bright Hour,’ by Nina Riggs and ‘The Art of Death,’ by Edwidge Danticat

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The Art of Death

By Gayle Brandeis

In her 1993 Nobel lecture, Toni Morrison said, “We die. That may be the meaning of life. But we do language. That may be the measure of our lives.” Nina Riggs and Edwidge Danticat both “do language” to explore mortality in their new books, charging each page with both measure and meaning.

Riggs’ deeply moving “The Bright Hour: A Memoir of Living and Dying” takes its title from a quote by Ralph Waldo Emerson — who, we learn, was Riggs’ great-great-great-grandfather. Riggs, a poet who clearly inherited her famous ancestor’s insight and wit, leads us through all four stages of her journey with metastatic breast cancer, which — cruelly, and at times, hilariously — intersects with her mother’s cancer journey; her mother goes into hospice and dies not long after Riggs’ mastectomy. Dark stuff, but “The Bright Hour” is indeed suffused with brightness — a series of luminous reminders that “the beautiful, vibrant, living world goes on” even in the midst of pain and loss. Riggs died in February, shortly after completing the book; her widower, John Duberstein, provides a touching afterword.

Danticat’s “The Art of Death: Writing the Final Story,” is part of Graywolf Press’ “The Art of” series in which authors explore specific craft elements of creative writing. The book offers a critical examination of how and why writers — a broad, at times dizzying, array, including Zora Neale Hurston, Joan Didion, Gabriel Garcia Márquez and Danticat herself — address death in their work.

“We write about the dead to make sense of our losses,” she writes, “to become less haunted, to turn ghosts into words, to transform an absence into language. Death is an unparalleled experience, so we look to death narratives, and to the people in our lives who are dying, for some previously unknowable insights, which we hope they will pass on to us in some way.”

These books are somewhat the inverse of one another: Riggs weaves literary criticism into her memoir, while Danticat weaves memoir — focused largely, wrenchingly, on her own mother’s death from cancer — into her literary criticism. Both writers quote Michel de Montaigne, who wrote extensively about mortality in the 16th century — Riggs, in fact, prefers his crankiness over her great-great-great-grandfather’s rhapsodies. He even becomes a muse of sorts to Riggs; she writes, “I can hear Montaigne hollering: break it open, look inside, feel it, write it down.”

“The Art of Death” helps explain why “The Bright Hour” is so affecting. “The more specifically a death and its aftermath are described,” writes Danticat, “the more moving they are to me. The more I get to know the dying person on the page, the more likely I am to grieve for that person.” Riggs writes about her own dying — and living — with stunning, tender, specificity. Take, for example, her obsessive quest for the perfect couch. After musing over how she can figure out how to let go of everything in her life but mothering her two young sons, she writes, “So maybe I don’t try to figure it out. Maybe I just aim to get the couch right: strong bones, high quality leather, something earthy and animal and real. A surface that knows something of what it was to be alive, that warms to our touch and cools in our absence.”

Danticat allows us to mourn her mother through closely observed detail as well, showing us the purses her mother left behind, filled with hard caramel candy, letting us hear her mother’s charming turns of phrase such as this one, translated from her mother’s Haitian Creole: “Most of us enter this world headfirst, then we leave it feetfirst.”

Danticat notes that humor can help keep death narratives from becoming “overindulgent, self-righteous, self-piteous, melodramatic, sentimental, or a combination of some of the above.” Riggs peppers her writing with a great deal of humor, as in this passage after she starts using a cane: “I’m pretending that I’m starting a hip new craze that people don’t even know about yet — like vaping or lumberjack beards or bone broth. Canes: the new frontier in walking. Like walking only better. Extra virgin, cold-pressed walking.” She clearly came by her sense of humor from her mother, who, while in hospice, delighted in responding to funny texts with “the Bitmoji with a hand coming out of a grave that says ‘Literally dying!’”

Both books serve as wake-up calls, bracing reminders to live while we are alive, to appreciate this gorgeous, absurd world of ours — and the people we love within it — while we can. As Riggs quotes from Montaigne’s final essay: “Let us make good use of our time. We still have so much of it that remains idle and ill-used.”

Complete Article HERE!

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10/13/17

Caitlin Doughty Talks Exploring the World to Find a Better Death in From Here to Eternity

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By Bridey Heing

The question of what happens when we die—in a literal rather than philosophical sense—haunts many of us. But few have made it the focus of their life’s work like Caitlin Doughty. An advocate for shifting the conversation about the “right” way to care for deceased bodies, Doughty owns a Los Angeles funeral home and organizes events where people discuss death with a range of approaches. Her latest book, From Here to Eternity, explores death culture around the world, illuminating the many ways to hold a funerals.

Doughty describes herself as having always been interested in death, but it was after studying Medieval History that she wanted to learn in a more hands-on setting. “When I graduated from college,” she says in an interview with Paste, “I decided that I wanted to see what real dead bodies look like and how they were being taken care of and disposed of.” She found an opportunity when she got a job at a crematory, where she immediately felt a connection to the work. “It’s hard to describe to people, but really from the second that I started working at the crematory, it was like, ‘Oh, this is what I’m supposed to be doing.’”

Doughty immediately recognized that the knowledge gap between the funeral industry and the general public is significant; she says no one quite knows what happens with a body after death. So not only did she want to learn more about the American way of death, but she wanted to talk about it with others. Her first book, Smoke Gets in Your Eyes, chronicled her journey into the funeral industry. And if she needed any indication that people were willing to listen, the fact that the book was a bestseller suggests that there is a desire to learn more about what takes place behind the scenes.

Doughty received a similar response a few years earlier when she founded the Order of the Good Death, an organization dedicated to expanding our understanding of and comfort with death. The organization established a space where everyone from academics to creatives could discuss death. “I was trying to create a community around death, and over the years it has become a resource. It’s hopefully a place where the culture of silence around death can, even just for a moment, be broken.”

Breaking the culture of silence around death is the heart of From Here to Eternity. Each chapter focuses on one or two cultures that handle death in unique ways. In Indonesia, Doughty watched as mummies were taken out of special house-slash-tombs to be feted. In Japan, she visited hotels where families spent time with loved ones’ corpses before cremation. In Colorado, she witnessed an open-air pyre where the community came together to honor the dead. In Bolivia, she made offerings to skulls called natitas, which were dressed up and paraded in the streets during the annual festival in their honor.

Doughty’s mission with her new book is to start a conversation about death in other cultures in a way that says something about U.S. funeral culture, and she wants to communicate the significance of rituals other than our own to combat a lack of cultural relativism.

“I see over and over again people talk about American death tradition, like embalming and burial in a big vault underground, and not liking that at all,” Doughty says. “But at the same time, whenever they heard about something that goes on overseas, they’d go, ‘Ugh, that’s so disrespectful and morbid.”
From Here to Eternity humanizes rituals that might otherwise seem unfathomable. “Even the things that are so out there by our standards feels so normal when you’re there. I wanted to get across that just because it’s not what you do doesn’t mean it’s weird or morbid or should be disparaged.”

Doughty’s text about the way families interact with their deceased loved ones is incredibly moving. But she doesn’t lose sight of her own role as an outsider observing a deeply intimate ritual, and she even talks about the ways in which death tourism has become an issue in countries with well known ways of handling their dead.

“You go into it thinking, ‘I have the best intentions, I’ve spent my life researching these things.’ But the family doesn’t know that,” she says. Doughty relied on local contacts and close friends, who could make sure she didn’t overstep while families were grieving. “The places I chose to go were places I had some in, whether that was a local guide or a person I know who travels all the time to these places.”

While the book has an international focus, the message is clearly one of a domestic nature. The shadow of how the United States handles death is always present, and Doughty dips in and out of her travel narratives to contrast what she sees with what she experiences in her own work. She also questions the very foundations on which the United States has built its funeral industry, including supposed health concerns that have led to profit-driven models of post-death care that many funeral homes require.

Doughty ultimately wants to change the way we talk about and experience death for a simple reason: she regularly hears about how frustrated Americans have been with their own experiences grieving loved ones. “This is my country and my own industry that I work in and own a funeral home in, and it doesn’t seem to be working for a lot of people,” she says. “If I didn’t hear that again and again, I wouldn’t keep doing this work.”

Doughty doesn’t advocate anywhere in the book for one system over another, but she does reveal that the U.S. system as it exists is deeply flawed. Her goal is to explore better ways to handle death, and in this, From Here to Eternity succeeds.

Complete Article HERE!

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07/28/17

How to write about death

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By Michael Upchurch

In a beautiful passage, early on in her new book, Haitian-American author Edwidge Danticat explains, “We write about the dead to make sense of our losses, to become less haunted, to turn ghosts into words, to transform an absence into language.”

Danticat’s own masterpieces — her memoir of her father’s and uncle’s deaths, “Brother, I’m Dying”; her novel-in-stories about a Haitian torturer, “The Dew Breaker”; and her early collection of tales, “Krik? Krak!” — have done exactly that. Her prose is often cool and taut on the surface, yet also rife with hidden currents and flashes of warmth. At her best, Danticat taps into such tough subject matter as political exile, mob violence, and refugee desperation with a trickless, spellbinding clarity.

The strongest thread in “The Art of Death: Writing the Final Story” (one in a series of Graywolf Press titles addressing specific aspects of the craft of writing) is her account of her mother’s reaction to being diagnosed with stage 4 ovarian cancer.

“In the car on the way home,” Danticat remembers, “we were both lost in a terrible silence that should have been filled with tears. At a red light, where I stopped for too long, my mother spoke up for the first time since we’d heard the news and warned, ‘Don’t suddenly become a zombie.’ She was telling me not to lose my good sense, to keep my head on my shoulders.”

Her mother brought humor even to the most humiliating hospital situations. To a nurse who had trouble drawing blood from her, she wisecracked, “It’s too bad you’re not like those vampires on TV who just put their teeth on someone’s neck.” When, toward the end, she opted out of repeated rounds of chemotherapy, she couldn’t have been more straightforward about it. “I’m not necessarily dying either today or tomorrow,” she said. “But we all must die someday.”

Danticat’s portrait of her is kind and loving. It also is, inevitably, anguished in its sense of loss. “I was shocked,” she says, “by how quickly many others expected me to bounce back and rejoin the world.”

But “The Art of Death” isn’t simply a memoir. It looks at how other authors have dealt with death in their writing. Danticat’s focus is on Tolstoy, Camus, Chekhov, Gabriel García Márquez, Toni Morrison, Audre Lorde and more than three dozen others. She touches on her own work as well.

It’s an impossible task, and Danticat’s attempts to order her thoughts on suicide, bereavement, and death-row prisoners’ experience can be unwieldy. She’s less assured when analyzing someone else’s text than she is when evoking her own experience. Her extensive commentary on Morrison’s novels, for instance, can’t compete with Danticat’s direct dealings with death.

Danticat is a straight shooter as a writer, so perhaps it’s not a surprise that she gives no nod to the thumb-nosing irreverence toward death you find in Laurence Sterne’s “The Life and Opinions of Tristram Shandy, Gentleman” (or, more recently, Monty Python). Some readers may also feel it odd that she omits such obvious candidates as Virginia Woolf and — ahem — Shakespeare from this discussion.

But a full study of how authors address death in their work would run to multiple volumes, and the format of Graywolf’s “The Art of” series puts firm constraints of length on its authors.

Danticat does make many essayistic observations that serve the book well — conclusions that she, looking inward, came to on her own. She notes the way we sometimes find ourselves “rehearsing” our future bereavements. She questions how one can “prepare to meet death elegantly.”

“We are all bodies,” she writes, “but the dying body starts decaying right before our eyes. And those narratives that tell us what it’s like to live, and die, inside those bodies are helpful to all of us, because no matter how old we are, our bodies never stop being mysterious to ourselves.”

For authors, the elusive nature of death never stops posing a challenge.

“Having been exposed to death does help when writing about it,” Danticat notes, “but how can we write plausibly from the point of view of the dying when we have not died ourselves, and have no one around to ask what it is like to die?”

Far from being morbid, this small book is a bracingly clear-eyed take on its subject.

Complete Article HERE!

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04/19/17

At the End of Life, a Way to Go Gentle

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While confronting the prospect of death, people like me — grappling with a diagnosis of advanced cancer — often consider what sort of care they want and how to say goodbye. Given the delicate negotiations in which the dying need to engage, do intensive care physicians with their draconian interventions act like proverbial bulls in a china shop? My fear of pointless end-of-life treatments, performed while I was in no condition to reject them, escalated when I read Dr. Jessica Nutik Zitter’s book, “Extreme Measures: Finding a Better Path to the End of Life.”

Dr. Jessica Nutik Zitter

Dr. Zitter confronts the sort of scenario that haunts me because she works in specialties that are sometimes seen as contradictory: pulmonary/critical care and palliative care.

In her new book, she refers to the usual intensive care unit approach as the “end-of-life conveyor belt.” She argues that palliative care methods should be used to slow down and derail the typical destructive I.C.U. approach that often torments people it cannot heal.

Over the past few years, quite a few studies have indicated that physicians are less likely than the general population to receive intensive care before death. Many doctors choose a do-not-resuscitate status. Dr. Zitter highlights the insight upon which her colleagues base their end-of-life decisions.

According to Dr. Zitter, even what are intended to be temporary intensive care measures can put a patient on that conveyor belt to anguish and isolation. She writes of breathing machines, feeding tubes, cardiac resuscitation, catheters, dialysis and a miserable existence prolonged within long-term acute care facilities. In an account of the evolution of her own ideas about doctoring, she also explains why it remains so difficult to change intensive care units so they can better serve the terminally ill.

“Extreme Measures” analyzes a complex cluster of suspect but ingrained attitudes that bolster hyperaggressive methods. Medical training fosters a heroic model of saving lives at any cost. American can-do optimism assumes all problems can and should be solved. Both doctors and patients tend to subscribe to a “more is better” philosophy. If technology exists, surely it should be used. Physicians’ fears of litigation plays a part, as do patients’ fantasies of perpetual life. For too many, death remains unthinkable and unspeakable.

One of Dr. Zitter’s compelling patient narratives teaches a clear-cut lesson. It involves an 800-pound man “too large to fit into the CT scanner,” but “too unstable to be transported to the nearby zoo’s CT scanner.” Surgery would therefore be impossible. The patient, a 39-year-old she calls Charles, is bleeding from his intestinal tract, his heart is exhibiting erratic behavior, his kidneys have failed and his liver is foundering. Yet he and his relatives want the doctors “to do everything.”

Although Dr. Zitter tries to explain to Charles and his family that chest compressions would break his ribs and electric shocks would burn his skin, they insist on “a full-court-press resuscitation attempt when he died.” To Dr. Zitter, “Running a code on this dying man felt… akin to punching him in the face and would probably have had the same utility.” Honoring his wishes would require breaking the oath: “First, do no harm.”

Other case histories in “Extreme Measures” are more troubling because their moral implications are less obvious. After a dramatic brain bleed from a major clot, a 45-year-old she calls George faces an operation that cannot return him to who he had been. His wife wants to know what Dr. Zitter would do if he were her husband. She explains that her husband would accept paralysis if he could remain communicative with her and their children at home.

Although Dr. Zitter fears that the surgeons who operated on George never broached the topic of his quality of life after surgery, she is heartened upon his return to the I.C.U.: He gives a thumbs-up. “What if, as a result of our talk, his wife had not consented to the surgery? Would I have been his unwitting killer?” This moment of self-doubt is followed by another turn of the screw. When Dr. Zitter later phones George’s wife, she says: “I am a single mother, but with another angry child.”

“Extreme Measures” includes a number of stories that explore the difficulties of talking about the subject of death with dysfunctional families, wracked by depression or feuds, and across racial, religious and ethnic divides. Often and to her credit, Dr. Zitter finds herself baffled, unsure of how to balance cultural priorities, human needs and medical possibilities. Throughout, she struggles personally and professionally to redefine common responses to terminal conditions.

In place of hope for recovery, Dr. Zitter emphasizes “the miracle of time at home, of pain management, of improved quality of life. These are all concepts I have seen families embrace in place of survival — the only concept of hope previously imagined.” And to people refusing “to play God” by withdrawing a breathing tube, she asks whether “they were playing God by keeping [a relative] alive when her body was actively dying.”

For readers who wish to avoid the end-of-life conveyor belt, Dr. Zitter concludes “Extreme Measures” with some practical advice on, for example, procuring a Physician Order for Life-Sustaining Treatment (POLST), a legal directive that emergency responders, paramedics and emergency room doctors are supposed to follow (but sometimes don’t, as Paula Span reported in The Times earlier this week).

Without this sort of documentation of end-of-life wishes, Dr. Zitter writes, a 90-year-old with metastasized prostate cancer ended up paralyzed and tethered to machines after cardiac arrests. “Our well-intentioned resuscitative efforts had crushed his cancer-weakened neck bones, rendering him quadriplegic.”

Passionately and poignantly, Dr. Zitter reminds us that “conveyor belts, regardless of their destination, are not meant for human beings.” Sometimes less is more.

Complete Article HERE!

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01/16/17

Death and the Irish: A miscellany

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 Do we ‘do’ death best?

Collection features 75 perspectives on death in Ireland and whets appetite for further study

“The Humours of an Irish Wake as celebrated at St Giles London.” Original artwork: engraving by Thornton, published by Johnson c 1750.

By Bridget English

The Irish wake is nearly as celebrated and stereotypical an Irish export as Guinness, leprechauns or shamrock. Its reputation as a raucous, drunken party that celebrates the life of the deceased is now regarded internationally as a desirable way to mark the end of one’s life, even for those who claim little or no Irish heritage.

It is conceivable, then, given the famous link between Ireland and death, that the Irish “do death well”. Where does this association come from? Do the Irish really “do” death better than anyone else? These are some of the questions behind a new collection of essays, Death and the Irish: A miscellany, edited by Salvador Ryan, a professor of ecclesiastical history at St Patrick’s College Maynooth.

The collection is part of a recent surge of academic interest in death and dying, as is evidenced by the publication of edited collections such as Grave Matters, Death and Dying in Dublin, 1500 to the Present (2016), edited by Lisa Marie Griffith and Ciarán Wallace, and Death and Dying in Ireland, Britain and Europe: Historical Perspectives (2013), edited by James Kelly and Mary Ann Lyons, both of which explore these themes from a historical perspective.

>Subtitled “a miscellany”, Death and the Irish is different from these publications because it features a medley of 75 perspectives on death and the Irish from historians, hospice workers, geographers, sociologists, anthropologists, theologians, priests, librarians, musicologists, and funeral directors, to name a few. It also covers a vast time span, taking readers from the fifth century to the present day.

Entertainment

The brevity of the essays (around three to four pages, including footnotes) and their pithiness, though a departure from the extended discussions commonly found in academic anthologies, is true to the form of the miscellany, which was originally intended for the entertainment of contemporary audiences.

Death and the Irish will interest readers looking for interesting tidbits of information on death and provides ample fuel for those searching for inspiration for further research.

Some tantalising morsels from the miscellany include: the tale of a young woman buried with her horse sometime between 381 and 536 AD; the variety of terms for death in the Irish language; social media’s role in keeping memories of the dead alive; an analysis of Stuart-era funerary monuments and what they reveal about women’s role in society; the 18th-century Dublin practice of laying executed corpses at the prosecutor’s door; a quirky account of the discovery of James McNally’s death by elephant in Glasnevin cemetery’s burial registers; and the story of a young cabin boy’s death by cannibalism.

Given the number of entries included in the volume, it is not possible to provide a detailed account of each, but a few entries are worth mentioning. Clodagh Tait’s Graveyard folklore and Jenny Butler’s The ritual and social use of tobacco in the context of the wake are particularly thought-provoking accounts of folk practices and the material cultures surrounding death. Tait’s gruesome description of the pieces of human remains that were collected for charms and the dead man’s hand that “could be used to make churning butter less onerous” provides readers with images that they are unlikely to soon forget.

One downside of Death and the Irish is that the experience of reading such short essays can be frustrating for anyone (particularly students) coming to the collection looking for an extended discussion of death practices in a particular era. Organising the entries by time period or by theme (burial, folklore, historical figures or events, etc) might make for more streamlined reading, but to do so would also destroy one of the collection’s main strengths, which is to bring disparate approaches together, taking interdisciplinarity to an extreme, provoking new ideas through a multilayered view of death in Ireland.

Under-represented

Despite the inclusiveness of Ryan’s miscellany, certain disciplines, such as history and theology, seem to dominate, while others are absent or under-represented. Philosophers have certainly shaped the ways that modern secular society conceives of death, yet there are no entries on the relationship between Ireland and philosophy.

Irish film, literature and drama feature some of the most insightful and humorous portrayals of death and dying in western culture, yet there are only three entries on literature, and these are limited to poetry (Irish language poetry, bardic poetry and 18th-century elegies).

These are minor criticisms and on the whole, Death and the Irish: A miscellany is commendable for its inclusion of marginalised groups such as Travellers, and for the links made between Irish practices and Jewish and Muslim beliefs. The Irish may not necessarily “do” death better than anyone else, but as this volume makes clear, the history and rituals surrounding death offer a rich and complex area of study, one that has much to tell us about Irish attitudes towards mortality and treatment of the dead.

Complete Article HERE!

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